Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy Glyn Griffiths is one of the noble band of WIHSC Associates on whom we rely for much of our work. A pharmacist by training, and a … Continue reading →

» A personal reflection on the structural changes in health and social care in Wales

Introduction by Professor Marcus Longley, Director of WIHSC and Professor of Applied Health Policy This week’s blog is by another long-term friend of WIHSC, Tony Garthwaite, Senior Fellow at the Institute. Many readers will remember Tony as a leading figure … Continue reading →

Tuesday’s news that the NHS in Wales will need to cut more than £380m by April will have come as no real surprise to anyone. Commentators are beginning to run out of clichés and euphemisms for the process of making cutbacks, and the announcement of the findings of Comprehensive Spending Review on October 20th is focusing. The Spending Review is clearly the major political show in town, and has provided more column inches than any other single issue since the coalition came to power. Indeed it has provided the first significant dividing line in the Labour leadership contest – with different views on the speed of deficit reduction and the role of the state providing some clear water between the candidates.

Inevitably attention within the debate on cuts in health is drawn to hospitals and keeping people out of them – but this is just as much about community services in both health and social care. Whatever the focus, in order to achieve the level of cutbacks that are being proposed, politicians and other decision makers are going to impact heavily on local people who will be feeling the pinch most acutely – either because their service has been cut and/or because they have been directly affected as their job is threatened. With such high levels of public sector employment in Wales this double hit is clearly something those charged with implementing the cuts are trying to avoid.

A few brave souls are still talking about these deficit reduction measures in terms of an opportunity to re-shape and re-design for the better, but these voices are being drowned out by the deep and legitimate concerns of communities that their services are under threat and may be lost.

All of this is very familiar, so why post a blog on what we already know? Well, for me, what has been surprisingly missing from debates so far have been questions about how major changes would be made if the threat of financial meltdown was not hanging over our heads. In an ideal world, any such major reconfiguration of services would be justified by providing clear evidence that doing things differently will improve outcomes for service users and patients. Full stop. If that could save money, then great, but that would not be the primary driver. Achieving such change would require fundamental questions to be asked about what, when, how and even why services are provided. But equally fundamentally are a series of questions about the nature of the relationship between us and those that provide services which would need to be considered. This would lead to a different type of partnership – one based on mutual respect and a re-balancing of power – between patients, service users, their families and the professionals that care for them. This partnership is essential to developing new relationships connecting citizens with their health and social care organisations so that they use them differently in the future.

Now, that’s a rather naïve position to take, you might think, given the financial realpolitik of our current situation. But let’s just for a moment move away from all of the clamouring voices and consider how services might look five years from now.

Services will still be severely financially constrained and providing on a more limited basis than now. In all likelihood fewer people will be working in the health and social care sector. The nature of the patients and service users they see may be different given that higher thresholds for receiving treatment or care may well be operating. There may well be fewer buildings from which services are provided and more delivered in community settings. But people will still need treatment and will still need caring for. And if we do not seize the opportunity to re-design the nature of the relationship at the individual level then, to use a well-worn and hackneyed phrase, the crisis will have been well and truly wasted.

I am sure that most readers followed the MP’s expenses coverage with a real sense of outrage, but we were all assured that the introduction of the Independent Parliamentary Standards Authority has resolved the problems. It was disappointing to read the account of a meeting which took place recently between senior representatives of that Authority and current MP’s, at which one MP claimed that IPSA had ‘destroyed the whole sense of public service’. It is difficult not to assume that this wanton destruction is based on the requirement to actually submit receipts for expenses!

I suppose I had actually assumed that anyone putting themselves forward as an MP, now or in the past, would actually have some form of innate understanding of what public service values mean.

These thoughts evolved into my reflections on a study tour to Canada some years ago. North American hospitals are all proud of their mission statements. Visitors will, almost inevitably, see these fine words engraved on brass plaques at the entrance to the hospital. Out of curiosity, I Googled ‘hospital mission statement’ and got 2 million results! I read enough of them to become rapidly bored and somewhat disillusioned. I will happily buy a glass of wine for any reader who can find one that does not contain the word ‘excellence’ and a second glass for anyone who can find one that actually defines what excellence means.

Returning to my Canadian visit, our study group visited a newly established Canadian hospital, where we were told the tale of how they had developed their own statement. Unsurprisingly, they called the senior management team together for a facilitated ‘time out’. The facilitator asked the team to make a list of the key words that should appear as part of the hospitals mission. Their work produced more than 20 such words, and yes, excellence was one of them. They were persuaded that rather than producing 250 bland and forgettable words of infinite wisdom, they should instead consider a simple statement of values. What they came up with eventually were 3 extremely simple criteria against which they felt that their services could be measured. They were respect, partnership and continuous improvement. They claimed that every single task performed by any employee, in any situation can be assessed against these 3 criteria. They were right, as visitors we tried it and found that anything from cleaning the toilets to performing open heart surgery can indeed be assessed in that way. So their mission turned away from a long winded statement about what they do to a much simpler statement about how it is done.

Perhaps, that is the missing link in defining what public service means. Perhaps, the existence of a simple set of criteria about how public servants should do things would have avoided expenses scandals and avoided what seems to be the ongoing aftermath. Sadly my experience, based on the old adage that a camel is a horse designed by a committee leaves me concerned that such a venture might produce a list of 15 to 20 undefined terms – but hell we could give it a go and perhaps, just perhaps, define what public service will actually mean to both those who use those services and the people who provide them.

The study tour I referred to was part of a management development programme run by the King’s Fund College and the main message I took from this programme was not about the mechanics of management, but instead the importance of managing against a set of values. Value based management is hard work, there were countless occasions where I found myself apologising to people for not always living up to my own values. However, having values and telling people what they are raises standards.

In closing, I will share a story from my days on that King’s Fund programme. I had a friend at the time who was a manager of a store in a major retail chain; we spent many an evening in the local pub whilst I regaled him with my new found enthusiasm for value based management. He became enamoured with the concept (after all becoming enamoured gets a lot easier after a few beers) and decided that he would try and take this into his own organisation. His opportunity came at his bi annual review with the regional manager. This was done to a structured format, part of which was a presentation by my friend on pre prepared flip charts. On revealing the title of his presentation on values he instantly saw the unenthusiastic, if not hostile reaction on his bosses face. Of course he had no real choice but to continue with his pre prepared work, all the while seeing the boredom and irritation being displayed in front of him. His final chart was a brief list of his own personal values. His final words to his by now thunderously annoyed superior were ‘So, these are my values. But if you don’t like these I have others!’

Not many years later, that retail chain went broke and closed. I would so dearly love to believe that their end may have had something to do with a lack of articulated values.

I am sure that most readers followed the MP’s expenses coverage with a real sense of outrage, but we were all assured that the introduction of the Independent Parliamentary Standards Authority has resolved the problems. It was disappointing to read the account of a meeting which took place recently between senior representatives of that Authority and current MP’s, at which one MP claimed that IPSAhad ‘destroyed the whole sense of public service’. It is difficult not to assume that this wanton destruction is based on the requirement to actually submit receipts for expenses!

I suppose I had actually assumed that anyone putting themselves forward as an MP, now or in the past, would actually have some form of innate understanding of what public service values mean.

These thoughts evolved into my reflections on a study tour to Canada some years ago. North American hospitals are all proud of their mission statements. Visitors will, almost inevitably, see these fine words engraved on brass plaques at the entrance to the hospital. Out of curiosity, I Googled ‘hospital mission statement’ and got 2 million results! I read enough of them to become rapidly bored and somewhat disillusioned. I will happily buy a glass of wine for any reader who can find one that does not contain the word ‘excellence’ and a second glass for anyone who can find one that actually defines what excellence means.

Returning to my Canadian visit, our study group visited a newly established Canadian hospital, where we were told the tale of how they had developed their own statement. Unsurprisingly, they called the senior management team together for a facilitated ‘time out’. The facilitator asked the team to make a list of the key words that should appear as part of the hospitals mission. Their work produced more than 20 such words, and yes, excellence was one of them. They were persuaded that rather than producing 250 bland and forgettable words of infinite wisdom, they should instead consider a simple statement of values. What they came up with eventually were 3 extremely simple criteria against which they felt that their services could be measured. They were respect, partnership and continuous improvement. They claimed that every single task performed by any employee, in any situation can be assessed against these 3 criteria. They were right, as visitors we tried it and found that anything from cleaning the toilets to performing open heart surgery can indeed be assessed in that way. So their mission turned away from a long winded statement about what they do to a much simpler statement about how it is done.

Perhaps, that is the missing link in defining what public service means. Perhaps, the existence of a simple set of criteria about how public servants should do things would have avoided expenses scandals and avoided what seems to be the ongoing aftermath. Sadly my experience, based on the old adage that a camel is a horse designed by a committee leaves me concerned that such a venture might produce a list of 15 to 20 undefined terms – but hell we could give it a go and perhaps, just perhaps, define what public service will actually mean to both those who use those services and the people who provide them.

The study tour I referred to was part of a management development programme run by the King’s Fund College and the main message I took from this programme was not about the mechanics of management, but instead the importance of managing against a set of values. Value based management is hard work, there were countless occasions where I found myself apologising to people for not always living up to my own values. However, having values and telling people what they are raises standards.

In closing, I will share a story from my days on that King’s Fund programme. I had a friend at the time who was a manager of a store in a major retail chain; we spent many an evening in the local pub whilst I regaled him with my new found enthusiasm for value based management. He became enamoured with the concept (after all becoming enamoured gets a lot easier after a few beers) and decided that he would try and take this into his own organisation. His opportunity came at his bi annual review with the regional manager. This was done to a structured format, part of which was a presentation by my friend on pre prepared flip charts. On revealing the title of his presentation on values he instantly saw the unenthusiastic, if not hostile reaction on his bosses face. Of course he had no real choice but to continue with his pre prepared work, all the while seeing the boredom and irritation being displayed in front of him. His final chart was a brief list of his own personal values. His final words to his by now thunderously annoyed superior were ‘So, these are my values. But if you don’t like these I have others!’

Not many years later, that retail chain went broke and closed. I would so dearly love to believe that their end may have had something to do with a lack of articulated values.

The parties’ general election manifestos show just how different health policy in England has become from that in Wales.

The manifestos, of course, are talking about the English NHS. Superficially, England and Wales seem to share some objectives, such as improved access to care, protecting investment in the NHS, and spending money wisely. But the latest eye-catching ideas from England seem to have little to do with Wales.

The three main parties all agree on the key issue for England – how to drive up the performance of the NHS. Their shared recipe has three ingredients: help NHS workers take over and run their own services; encourage a range of provision; and give people lots more information on how well local services are performing.

This is as far from the debate in Wales as would be discussion about the merits of SATs in schools, or the transport infrastructure around the Olympic stadium.

Our ingredients for driving up performance include getting the public sector to work together, encouraging clinical networks and benchmarking, and a strong steer from the centre.

Contrast this with English Labour, where all the talk now is of getting good performers to take over the poorer ones, enshrining patient rights in legislation, and making primary care available from “8 ‘til late”.

The difference is startling, as is the consensus amongst the main parties in England.

None of this difference need matter, of course, and actually it might be a good thing to experiment with different approaches and see which works best. A moment of quiet reflection, however, might reveal a paradox: how can we be proposing two so completely different approaches to improving the NHS – to achieving essentially the same goals? One might wonder whether anyone actually knows which approach is best, or whether we are not all going with our gut instincts and the herd?